Care and Respect in Death

Good Practice Guidancefor NHS Mortuary Staff

Care and Respect in Death

Good Practice Guidancefor NHS Mortuary Staff

READER INFORMATION

Policy EstatesHR/Workforce PerformanceManagement IM&TPlanning FinanceClinical Partnership Working

Document Purpose Best Practice Guidance

ROCR Ref: Gateway Ref: 6831

Title Care and Respect in Death: Good Practice Guidancefor NHS Mortuary Staff

Author DH Modernising Pathology Team

Publication Date 10 Aug 2006

Target Audience NHS Trust CEs, Foundation Trust CEs, MedicalDirectors, Directors of Nursing, Directors of HR, AlliedHealth Professionals, Communications Leads, Directorsof Pathology and Mortuary Managers in NHS Trustsand Foundation Trusts

Circulation List

Description Mortuary staff have an important and challenging role,providing an efficient, safe, secure service whileensuring care and respect in death and treatingbereaved families sensitively. This document sets outkey principles of good practice for staff in NHSmortuaries and provides advice on how thoseprinciples can be put into practice.

Cross Ref Modernising Pathology Services and ModernisingPathology: Building a Service Responsive to Patients

Superceded Docs N/A

Action Required N/A

Timing N/A

Contact Details Pathology Modernising TeamRoom 415, Wellington House 133-155 Waterloo RoadLondonSE1 8UG020 7972 4392

For Recipient’s Use

Foreword

1Care and Respect in Death: Good Practice Guidance for NHS Mortuary Staff

People working in mortuaries in NHS hospitals have an important andchallenging role. They have to balance a number of different needs – providingan effective, efficient, safe and secure service, while at the same time treatingbereaved families respectfully and sensitively.

The NHS cares for many people at the end of their lives and that care doesnot end when they die. Mortuaries are a vital part of the service the NHSgives to patients who die in hospital and to their bereaved families and friends.The services they provide are often overlooked. But good care after death isnot an optional extra. If things go wrong in a hospital mortuary, the impacton bereaved families can be devastating. Providing a high quality mortuaryservice which respects the dignity of deceased patients and their families is a keypart of effective support for bereaved families.

There is much good practice in NHS mortuaries, and many dedicated andcaring staff working in them. The advice in this document has been developedwith their insight, knowledge and experience. The Government’s aim is to putpatients at the heart of the modern NHS. Providing a service which ensurescare and respect in death is an important part of that vision. I welcome thepublication of this advice, which sets out eight key principles of good practiceand provides guidance on how those principles can be put into practice.

Norman WarnerMinister of State for NHS Reform

Contents

Foreword 1

Contents 3

Executive Summary 5

Chapter One Setting the Scene 7Introduction 7Background 8Eight key principles 9

Chapter Two Putting the Principles into Practice 11Introduction 11A service responsive to individual needs 11

Families’ needs 12The viewing room 15Preparing and presenting the body of the personwho has died 17Children and babies 18

A service that shows respect 19Release of a baby’s body to parents 19

A service that is safe and secure 21Standard operating procedures 21Health and safety 23Facilities 23Identification of the body of a person who has died 23Personal possessions on or with the body of a personwho has died 24Release of the body of a person who has died 24Children and babies 26

A service that is confidential 26A reflective service committed to improvement 27A service which values good communications 28A service that is fit for purpose 29A service which values its staff 30

3Care and Respect in Death: Good Practice Guidance for NHS Mortuary Staff

Annex A: Membership of the Mortuary Services sub-group 32of the National Pathology Oversight Group

Annex B: Workforce – the Anatomical Pathology 33Technology Workforce

Annex C: Sources of Further Information and Guidance 36

4Care and Respect in Death: Good Practice Guidance for NHS Mortuary Staff

Executive Summary

In February 2004, the Government published Modernising Pathology Services,good practice guidance to the NHS on building better pathology services. Thisset out a vision for NHS pathology services which would:

• be built around the needs of patients and their clinicians, seeing servicesfrom their perspective

• enable and empower staff to work across traditional boundaries to deliverthe highest quality care to all

• offer patients greater choice in where, when and how they accesspathology services

• be integrated into wider service developments and improvements.

This was followed in September 2005 by Modernising Pathology: Building aService Responsive to Patients. This set out how, in line with The NHS ImprovementPlan, the NHS could build a new pathology service shaped around the patient andindicated that the Department of Health would publish good practice advice forNHS mortuary staff.

People working in mortuaries have an important but challenging role. Theyneed to balance delivery of an effective and efficient service which followsstringent procedures to ensure safety and security, with the need to demonstraterespect and sensitivity for bereaved families.

This document is complementary to When a Patient Dies – Advice on DevelopingBereavement Services in the NHS 1 and to local standard operating procedures inmortuaries, and is designed to be read alongside them. It also does not seek toduplicate existing regulations and guidance for the performance of post-mortemexaminations. The focus of this document is on ensuring that NHS mortuariesdeal in a safe, secure and sensitive manner with the bodies of those who die inhospital or who are brought to the hospital mortuary after death.

5Care and Respect in Death: Good Practice Guidance for NHS Mortuary Staff

1 Published by the Department of Health in 2005, and available at www.dh.gov.uk.

It has been developed with advice from the Mortuary Services Sub-groupof the National Pathology Oversight Group. We are very grateful to thegroup for the time they gave to developing the document, and to the lateNancy Kohner, the independent consultant who facilitated it and contributedso much.

The document:

• sets out eight key principles of good practice for all staff working in NHSmortuaries

• provides guidance on how those principles can be put into practice.

6Care and Respect in Death: Good Practice Guidance for NHS Mortuary Staff

Chapter One

Setting the Scene

Introduction

1.1 People working in mortuaries have an important and challenging role.They need to balance delivery of an effective and efficient service whichfollows stringent procedures for ensuring safety and security, with theneed to demonstrate respect and sensitivity for bereaved families2 andmeet the needs of clinical staff.

1.2 This document sets out the eight key principles of good practice thatall staff working in NHS mortuaries, including Anatomical PathologyTechnologists (APTs), mortuary managers and pathologists3 will needto follow. Other hospital staff (clinical staff, porters, members of thebereavement team and hospital chaplains), those working in publicmortuaries and others involved in care after a death, such as funeraldirectors who have contact with the mortuary and with families aftera death, and Coroner’s officers who investigate sudden or unexpecteddeaths or deaths of unknown cause, will also find it a helpful guideto practice.

1.3 The guidance acknowledges that while mortuaries operate in differentways in NHS Trusts around the country (facilities vary, and mortuarystaff fulfil different roles), there are fundamental principles of goodpractice which will always apply. The practical guidance set out in thisdocument is based on those principles. It provides a basis for, but doesnot replace, the detailed standard operating procedures which everymortuary must have in place, and which will be adapted to local andindividual circumstances. Mortuary services will wish to check thoseagainst the principles set out in this document.

7Care and Respect in Death: Good Practice Guidance for NHS Mortuary Staff

2 The word ‘families’ is used throughout this document to mean the relatives, partners and close friendsof the person who has died. It is recognised that those who are bereaved by a death and who may havecontact with mortuary and other hospital staff are not always, or not exclusively, family members.

3 It is recognized that some of these roles will overlap in some cases.

Background

1.4 The reports of the inquiries at the Royal Liverpool Children’s Hospital4

and Bristol Royal Infirmary,5 published in 2001, the Chief MedicalOfficer’s response to the former,6 also published in 2001, and the 2002response from the Department of Health to the Bristol Royal Infirmary,7

all recognised the need for change in the way bereaved families are caredfor in the NHS. Since then, the Department of Health and NHS Trustsaround the country have worked to improve the quality of support forbereaved people and care for deceased patients, and to develop relatedservices, including pathology and mortuary services.

1.5 Modernising Pathology Services,8 published in 2004, acknowledgedthe importance of mortuary services and committed the Departmentof Health to working with key stakeholders to publish good practiceguidance for mortuary staff. Modernising Pathology: Building a ServiceResponsive to Patients,9 published in September 2005, re-iterated this.Since then, The NHS Improvement Plan10 commits the NHS to putpeople at the heart of the service and urges staff to work differently todeliver a world class high quality service. The Department of Healthhas also published advice for the NHS on bereavement services.11

1.6 This guidance, which has been developed with the help of the MortuaryServices Sub-group of the National Pathology Oversight Group (seeAnnex A for membership), is therefore an important part of a widerpicture of modernisation and reform in the NHS. It sets out eight keyprinciples to guide the development of good practice locally.

8Care and Respect in Death: Good Practice Guidance for NHS Mortuary Staff

4 Department of Health. The Royal Liverpool Children’s Inquiry Report. 2001. Available at www.dh.gov.uk.5 The Report of the Public Inquiry into Children’s Heart Surgery at the Bristol Royal Infirmary 1984-1995:

Learning from Bristol. 2001. Available at www.dh.gov.uk.6 Department of Health. The Removal, Retention and Use of Human Organs and Tissue from Postmortem

Examination. Advice from the Chief Medical Officer. 2001. Available at www.dh.gov.uk.7 Department of Health. Learning from Bristol: The Department of Health’s Response to the Report of the

Public Inquiry into Children’s Heart Surgery at the Bristol Royal Infirmary 1984-1995. 2002. Availableat www.dh.gov.uk.

8 Department of Health. Modernising Pathology Services. 2004. Available at www.dh.gov.uk.9 Department of Health. Modernising Pathology: Building a Service Responsive to Patients. 2005. Available

at www.dh.gov.uk.10 Department of Health. The NHS Improvement Plan: Putting People at the Heart of Public Services. 2004.

Available at www.dh.gov.uk.11 Department of Health. When a Patient Dies – Advice on Developing Bereavement Services in the NHS.

2005. Available at www.dh.gov.uk.

Eight Key Principles

1.7 While mortuary practice protocols may vary according to localcircumstances and needs, the eight fundamental principles outlined belowwill usually inform local good practice protocols and be a hallmark ofgood practice. They are based on an assumption that the needs of keystakeholders are to be met, whether the particular emotional and socialneeds of families, the professional requirements of clinical and other staff,or the need of an organisation in terms of local service profiles, theavailability of resources, and facilities.

Principle One: A service responsive to individual needs

1.8 Death and bereavement affect individuals in different ways. Theirresponse is also influenced by their beliefs, culture, religion, values, sexualorientation, life-style or social diversity. Mortuary service staff will be alertto individual needs, and be flexible in attempting to meet them.

Principle Two: A service that shows respect

1.9 Policy and practice in the mortuary will demonstrate respect towardsthose who have died, towards bereaved relatives and in the way people’sbodies are cared for.

Principle Three: A service that is safe and secure

1.10 High standards of security are essential to protect the bodies of those whohave died and to ensure that the needs of bereaved families can be met.Security involves both appropriate facilities and efficient systems andprocedures. The mortuary service environment will be properly secureand the highest possible standards of care delivered to the deceased andtheir bereaved families. Effective security systems, procedures and a pro-security culture among mortuary staff will be in place. Health and safetyand the prevention of infection are also vital aspects of the service.

Principle Four: A service that is confidential

1.11 Mortuary staff have access to sensitive information about people who havedied and about bereaved families. Information will be treated in accordancewith requirements for patient confidentiality.

9Care and Respect in Death: Good Practice Guidance for NHS Mortuary Staff

Principle Five: A reflective service committed to improvement

1.12 In order to maintain high standards of practice, regular review and audit ofmortuary services will be undertaken so that opportunities for improvementare identified and changes made as necessary. The review process and itsoutcomes will always be recorded.

Principle Six: A service which values effective communication

1.13 Patient care does not end with a person’s death. Mortuary servicesprovided by NHS Trusts are integral to the patient care pathway. Theywill be part of Trusts’ communication network, with good communicationbetween mortuary staff and the staff who use their services; and also withfamilies using those services and organisations outside the hospital.

Principle Seven: A service that is fit for purpose

1.14 Families and users of mortuary services will be confident that localpathology services provide a high quality service which meets nationalrequirements and takes account of professional protocols and guidelinesfor good practice across all aspects of the work they do.

Principle Eight: A service which values its staff

1.15 A high quality mortuary service is built on the skills and dedication of thestaff who manage and work in it. Given the nature of their work, staff willbe confident that they will be offered support and training opportunitiesto maintain and develop their knowledge, understanding, self-awarenessand skills.

10Care and Respect in Death: Good Practice Guidance for NHS Mortuary Staff

Chapter Two

Putting the Principles into Practice

Introduction

2.1 This chapter sets out how mortuary services across the country coulduse these principles to guide their practice and the development of localprotocols. It takes as its starting point the fact that mortuary services existto safeguard the bodies of people who have died, and proposes this bedone in a way that ensures the needs of bereaved families as well as anumber of other stakeholders are met. Their other key role is to facilitatethe conduct of post-mortem examinations, but that is outside the scopeof this document. In order to design a service that meets the needs ofbereaved families, the local community, clinicians, local authorities whohave responsibility for Coroners and others, mortuary services shouldinvolve these groups in service development and review. This isparticularly important where the mortuary serves a community withdifferent cultural and religious groups. Consultation and collaborationwith all sections of the local population will help to ensure that theservice provided is responsive and appropriate. Consultation anddiscussion with local communities and groups about their specific needsis a vital part of building understanding and good local practice.

A service responsive to individual needs

2.2 Where families have individual, cultural or religious preferences concerningthe storage, handling, transportation or presentation of the deceasedperson, these need to be carefully documented and accommodatedwherever possible. Families will be asked about their needs or preferencesand if these cannot be met, or difficulties occur, the reason explained anda compromise sought. (See also paragraphs 2.3 – 2.6 below on viewing.)For example, if the person who has died has left specific requests orinstructions, these should, where possible, be followed. A member of staff,either in the mortuary or on the ward, will also talk to relatives about whatthey want in relation to issues such as, for example, viewing the deceasedand wherever possible, their requests will be met. If requests cannot be met,

11Care and Respect in Death: Good Practice Guidance for NHS Mortuary Staff

an explanation will be given and, where appropriate, a compromise found.If there is a conflict between the wishes of the person who has died and thebereaved family, this will need to be discussed sensitively with the family.

Families’ needs

2.3 It may be important for bereaved families to see and spend time withthe person who has died during the time that they are in the mortuary.Mortuaries need to have in place policies to support good practicelocally.12

2.4 In a good mortuary service, families who wish to see the body of theirloved one will be able to do so (unless there are legal impediments).13

However, if the person’s body is decomposed or disrupted, it is goodpractice to offer advice and guidance to the family first. Coroner’s officersare very experienced in managing this. Although mortuary staff maysometimes feel anxious about a family viewing a relative if, for example,the family is very distressed or the deceased’s body is in a particularlypoor condition, seeing and spending time with their relative’s body can behelpful for bereaved people, even in extreme circumstances.

2.5 If a death has been referred to the Coroner, the deceased person’s body isunder the Coroner’s jurisdiction until the inquiry has been completed, andopportunities for the family to see their relative may be restricted. Inaddition, in homicide cases there may be further restrictions on viewingwhere the police raise concerns about contamination of forensic evidence.Arrangements to view should be made with the Coroner’s officer who willbe able to explain any restrictions.

2.6 It is important that mortuary staff, possibly along with other staff involvedin supporting the bereaved family, take responsibility for ensuring that,before a bereaved person or family decides to view their relative’s body:

12Care and Respect in Death: Good Practice Guidance for NHS Mortuary Staff

12 Occasionally the family may prefer to accompany the deceased patient from the hospital ward, and alsotake an active part in their removal from the mortuary.

13 See recommendations 25-30, Public Inquiry into the Identification of Victims Following Major TransportAccidents. Report of Lord Justice Clarke (Cm 5012) London: The Stationery Office 2001. While LordClarke’s recommendations relate primarily to the viewing of bodies in Coroners’ cases and followinga major disaster, the recommendations are also relevant to the viewing process generally.

• they are given information about what the mortuary is like, as wellas any security requirements they may be required to observe andwhat they will see

• they are given information about the condition of the deceasedperson’s body. It is vital that this information is given honestly,sensitively and clearly. Some people will want more detail thanothers. All should be given the chance to ask questions.14 It maysometimes be helpful for families to see a photograph, either toenable them to decide whether or not they wish to see the body oras preparation for viewing. If a photograph is taken for thesepurposes, it should be good quality and clear. The family should bereassured that, unless they want to keep it, the photograph will bedestroyed. (Photographs taken as part of a post-mortemexamination are different and separate. Next of kin should beinformed that these are likely to be retained)

• they are offered support. Some people may want to be alone withthe person who has died but others may choose to have the supportof a member of the mortuary staff, the bereavement team or achaplain. Alternatively, they may wish to bring someone of theirown choosing to support them

• they are given the opportunity to express any particular needs andpreferences about the presentation of their relative (for example,how he or she is covered or dressed), the timing of viewing, andany access requirements for disabled people

• they are told what they can (or cannot) do (see paragraph 2.2above). However, if the death has been referred to the Coroner, itmay not be possible for the family to care for the deceased personand the Coroner should be consulted. The situation should then becarefully and sensitively explained to the family, and time given torespond to their questions and concerns

• they know how to reach the hospital and, if they are coming by car,where to park.

13Care and Respect in Death: Good Practice Guidance for NHS Mortuary Staff

14 The impact of bereavement may make some people less able to be active in requesting information andexpressing their needs and preferences. Mortuary staff need to bear this in mind.

2.7 It can help families to have written information about the process to readin advance, but it should never be a substitute for information being givenverbally and in person.

2.8 Where a mortuary service is working well, families who choose to seetheir relative will be met in a part of the hospital that is familiar to themor easy to find, then accompanied to the mortuary. Ideally, the memberof staff accompanying them should have some contact with the familybeforehand – at least by phone – and the family should know theirname and role.

2.9 Viewing is generally dictated by opening hours and the availability ofmortuary staff. Where possible, families will be able to see their relative assoon as they wish. If this is not possible, reasons should be given andevery effort made to enable them to see the deceased’s body at the earliestopportunity.

2.10 Appointment times, once made, should always be honoured. It isextremely difficult for a grieving family to tolerate a cancellation. If thereis a delay, a member of staff must always meet the family at the appointedtime, apologise, and explain the problem.

2.11 Direct contact with their relative’s body cannot be refused in Coroner’scases unless there are concerns about interference with evidence (seeparagraph 2.5 above), but some may choose to see their loved one througha glass screen. Sensitive and informed discussion beforehand should helpthem to make the choice that is right for them. In rare circumstances wherethe risk of infection may mean that viewing or contact has to be restricted,this will be carefully explained to the family beforehand and time given toanswer their questions and respond to their feelings and concerns.15 (Wherethe family was not aware of the infection, however, this will need to becarefully managed to avoid breaching patient confidentiality.)

2.12 In some situations it may be helpful to repeat information about thedeceased person’s body before going into the viewing room or to givemore detailed information – for example, about any marks or damage,including the lines of stitching from a post-mortem examination. It isoften helpful to combine positive information with anything negative –although honesty is essential. For example, “She looks peaceful but quitepale,” or “He has a bruise on his cheek but there is no blood.”

14Care and Respect in Death: Good Practice Guidance for NHS Mortuary Staff

15 For further guidance on viewing of, and contact with, bodies which may present health risks, seeSafe Working and the Prevention of Infection in the Mortuary and Post-mortem Room. Health and SafetyExecutive, 2003; and A Handbook of Anatomical Pathology Technology. The Royal Institute of PublicHealth, 2004.

2.13 Some people will want time alone with the person who has died, otherswill want a member of staff to stay with them. In these circumstances,it is important that:

• they can feel absolutely assured of their privacy but can call someoneif they wish. Ideally, they should be able to call for a member ofstaff themselves (by use of a bell, for example). It is better to tell thefamily that they will not be disturbed for a certain length of timeunless they ask for someone to come than to say, for example, “I willcome back every now and then to see if you need anything.”

• they know what they can and cannot do (see paragraph 2.6 above).Any restrictions that are absolutely necessary should be carefullyexplained.

2.14 For some families, it is important that the family members are togetherwhen viewing the body of the person who has died. This may meanaccommodating quite a large group of people, possibly includingchildren. It is important to discuss the family’s needs beforehand and, ifspace is limited, explain the difficulty. Every effort should be made tomeet families’ needs or reach an acceptable compromise.

2.15 In the best mortuary services, before a family leaves, a member of staffwill be available to answer any questions or concerns. If facilities allow,the family may want to spend some quiet time in a private room beforethey leave.

The viewing room

2.16 A viewing room will usually be decorated and furnished in a way whichwill help people feel calm and cared for, with soft but not dim lighting,and easy chairs so that if they wish, relatives can stay with the deceasedperson for a while in comfort. Ideally, it should not be possible to hearnoises from elsewhere in the mortuary.16 There should be no religiousartefacts or symbols permanently displayed, but families should be askedif they would like a religious symbol to be made available.17 Ideallydrinking water and dedicated toilet facilities should be available tovisitors. Trusts may also wish to consider whether the approach to themortuary is appropriate and put in place any necessary improvements.18

15Care and Respect in Death: Good Practice Guidance for NHS Mortuary Staff

16 NHS Estates. Improving the Patient Experience – A Place to Die with Dignity: Creating a SupportiveEnvironment. 2005.

17 It may be helpful to have an indication of the direction of Mecca available.18 Also see NHS Estates. Improving the Patient Experience – A Place to Die with Dignity: Creating a

Supportive Environment. 2005.

2.17 Detailed recommendations about the layout of a viewing room and otherfacilities are given in Facilities for Mortuary and Post-Mortem Room Services.19

2.18 The deceased person’s body is likely to be moved into the viewing roomon a bier trolley, but in the viewing room itself the body must be on astable surface and easily accessible: some people will want to touch or holdthe person who has died, or sit comfortably beside them, maybe holdinghands; and some may be wheelchair users, or children. A raised dais is notappropriate: it is best for the deceased to be at normal bed-height.

2.19 Some families may need facilities for ritual washing of their relative’s body.Mortuary services should have in place a policy about access to suitablefacilities in such cases, within the Trust or, if this is not possible, locally.

Good practice example: Working with the communityto meet their needsMortuary Manager, Hull and East Yorkshire Hospitals NHS Trust:“We are working on an initiative in co-operation with our trust, the localauthority and the local Muslim community. We plan to convert a disusedfacility at one of the local cemeteries to make it suitable for families touse for preparation of their loved ones’ bodies according to their religion,such as ritual washing. In addition mortuary staff will work with thecommunity in providing professional help and advice to ensure the safetyof all concerned. We are working out the finer details now. Everyoneinvolved is very keen to see this facility up and running.”

Good practice example: Doing simple things wellMortuary Manager at North Middlesex University Hospital NHS Trust:“The facilities that we have in this old Victorian building can seemforbidding to patients’ relatives and I have found that sometimes, whenrelatives are viewing their loved ones’ bodies, they need a quiet space tobe alone for a while in the fresh air. I persuaded my Trust to fund abench seat outside the mortuary so that relatives could sit there untilthey were ready to return to dealing with the practicalities of death.”

16Care and Respect in Death: Good Practice Guidance for NHS Mortuary Staff

19 NHS Estates. Facilities for Mortuary and Post-Mortem Room Services (HBN 20). 2001.

Preparing and presenting the body of the person who has died

2.20 It is important that the deceased is presented in the best possible way.Mortuary services should have in place a policy on this issue. However,one person’s idea of good presentation may be very different fromanother’s and it is good practice to work in partnership with bereavedfamilies, making no assumptions and asking them about their preferencesand needs. Mortuary and bereavement services will need to have in placeclear and robust mechanisms for communicating information about thedeceased patient, or family care; this will ensure that any relevantinformation from the family is passed to mortuary staff. Mortuary staffcould consult with nursing staff who cared for the patient about specificdetails, such as how the patient wore a scarf or a brooch.

2.21 In developing a policy on preparing and presenting a deceased person forviewing, mortuary services will be aware that:

• while most families will wish their relative’s body to be cleaned,some may not. Some relatives may wish to see the body in the stateit arrived in the mortuary, some may wish to clean at least someparts of the body themselves, or their religion may dictate that thewashing is done as part of a religious ritual

• some may want the deceased person to be dressed or wrapped insomething of their choosing

• If a death has been referred to the Coroner, opportunities for thefamily to care for the deceased person’s body in these ways may berestricted. This should be discussed with the Coroner’s officer.

2.22 Mortuary staff will do all they can to meet individual families’ needs inpreparing and presenting their relative’s body, working with others ifnecessary. If there are needs which cannot be met in the hospital setting,a funeral director is likely to be able to help and this should be discussedwith the family.

2.23 If a family is viewing a relative following a post-mortem examination, it isvital that the deceased person’s body has been well restored.20 The familyshould be told, sensitively but clearly, about the condition of the bodyand should have the chance to ask questions. Some families will want aminimal amount of information, others much more, but none should

17Care and Respect in Death: Good Practice Guidance for NHS Mortuary Staff

20 Further information will be found in: The Royal College of Pathologists. Guidelines on Autopsy Practice.September 2002; The Royal Institute of Public Health. A Handbook of Anatomical Pathology Technology,2004, and the Healthcare Sciences National Occupational Standards (HCS NOS), published atwww.skillsforhealth.org.uk.

have to discover for themselves where, for example, incisions have beenmade. Mortuary services should have in place a policy on line removaland wounds on a deceased person’s body.

Children and babies

2.24 Parents may have preferences about how their child is transported to themortuary. Particularly in the case of babies, they may wish to carry thebaby themselves, or accompany the member of staff who carries the baby.In some hospitals babies are transported in a pram or a moses basket.

2.25 Mortuary services following good practice will ensure that the viewingroom is adaptable so it can also be an appropriate place for bereavedparents (and possibly other children) to spend time with their dead babyor child. The adult-sized bed or trolley will be replaced with a baby’s cribor cot, or an appropriately sized bed or trolley for a small child.

2.26 See paragraph 2.20 above for guidance on presentation. Parents maywant to cuddle their child – perhaps seated in a comfortable chair. Somemay want to wash or dress their child as a final act of caring. If so, it isimportant they know beforehand what they can do, and how it mightfeel, and that they are helped to do what they want and need.

2.27 It is not unusual for parents to want a particular significant toy, blanketor item of clothing to be with their baby at all times. Consideration needsto be given as to whether this is possible (and the reasons explained if it isnot), and how to ensure such possessions remain with the baby or child.

Good practice example: Learning from the expertsMortuary Manager, North Glasgow University Hospital NHS Trust:“We encourage our staff to work with embalmers to gain experience inrespectful presentation of the deceased. Local embalmers are encouragedto attend post-mortem rooms to help them understand the proceduresundertaken by pathologists and APTs.”

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A service that shows respect

2.28 When mortuary staff meet bereaved families, they will treat them withrespect, avoiding judgements, assumptions or stereotyping. It is importantthat staff are aware of diversity in the community they serve and are ableto respect and accommodate the diverse cultural and religious needs ofthe groups and individuals within that community.21,22,23 Close liaisonwith the bereavement service and the chaplaincy would be helpful.

2.29 All procedures involved in the receipt, storage and release of the deceasedperson’s body must be carried out respectfully. This means that people’sbodies should be cared for, handled and stored in a way which preservesthe dignity of the deceased person at all times – allowing for the fact thatsome procedures (most obviously a post-mortem examination) areinvasive. Respectful care is demonstrated by ensuring that:

• transport is appropriate. Ideally, for transportation to the mortuarya specially adapted trolley should be used so that the dead person’sbody is completely concealed

• patients and visitors do not see dead people being taken in and outof the mortuary

• the bodies of the deceased are labelled, kept covered and/orwrapped in a dignified way – bearing in mind the need for secureidentification – and in a way that will best preserve the person’sbody. Use of a wrist and ankle band is preferable to attaching alabel to the toe

• there are always sufficient staff available to move the bodies ofpeople who have died safely and respectfully, and all staff involvedbehave respectfully when doing this.

Release of a baby’s body to parents

2.30 Some parents may choose to take their deceased baby home in their owncar. If so, the baby will be released directly to them. The Trust should havea policy in place covering the procedures to be followed in such cases.

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21 Detailed information and guidance is provided in Henley A, Schott J. Culture, Religion and PatientCare in a Multi-Ethnic Society. A Handbook for Professionals. London: Age Concern. 1999.

22 Helpful information and advice is also included in Jogee M. Religions and Cultures – A Guide to Beliefs,Customs and Diversity for Health and Social Care Services. 6th edition 2004. R&C publications,Edinburgh.

23 See also A Handbook of Anatomical Pathology Technology, published by the Royal Institute of PublicHealth, 2004.

2.31 If the baby cannot be released to the parents in a Coroner’s case untilafter the enquiry, it is important the reasons are explained to the parents.

2.32 The arrangements will probably be facilitated by a member of thebereavement team, or by the midwife or neonatal nurse who has beencaring for the family. However, good liaison with the mortuary isimportant, and mortuary staff are likely to be involved. They need to beaware of the general procedure and also any individual arrangements orrequests. It is important that:

• parents are well informed, both about formalities to do withreleasing the child’s body and also the practicalities of transportingthe child and keeping the body for a time at home

• parents are aware of the state of the child’s body, and the likelychanges that will occur

• parents are supported in what they wish to do and their needs aremet wherever possible

• parents have a contact in the Trust whom they can phone if theyhave any query or difficulty.

2.33 It is important that parents are given choices and their wishes are metwherever possible. Planning beforehand, and making sure that everyoneinvolved is well informed, is vital.

2.34 For more information about the handling of babies’ bodies and parents’possible needs, see Pregnancy Loss and the Death of a Baby. Guidelines forProfessionals,24 and the website of the Child Bereavement Trust.25

Good practice example: Taking care of bereaved parentsBereavement service, Great Ormond Street Hospital for Children NHSTrust: “When a baby or child dies, the family sometimes want to takethem home for a while before the funeral. The hospital gives theparents a letter to carry, just in case they are involved in an accident orare stopped by the police for some reason, to help them avoid delayand distressing explanations.”

20Care and Respect in Death: Good Practice Guidance for NHS Mortuary Staff

24 Kohner N. Pregnancy Loss and the Death of a Baby. Guidelines for Professionals. London: SANDS. 1995. 25 Guidance for professionals is available on the Child Bereavement Trust website at

www.childbereavement.org.uk/professionals/membersarea.php, by logging in to the research andreference material.

A service that is safe and secure

2.35 Managing the receipt, storage and release of deceased people and theirproperty safely, securely, efficiently, effectively and appropriately is the corebusiness of mortuary services. It is, therefore, important that staff workin an environment which is properly safe and secure. Mortuary servicesshould liaise with the nominated Local Security Management Specialist(LSMS)26 on any security-related matters. The LSMS can assist with thepromotion of a pro-security culture27 and the deterrence, prevention anddetection of incidents. Security assessments should include:

• consideration of an integrated security solution, using acombination of physical controls or systems such as closed circuittelevision, locked and alarmed emergency exits, access controls,intercoms and remote door releases

• risk prevention for the avoidance of incidents

• arrangements for working out of hours.

2.36 Health and safety, and the prevention of infection, are also vital inmortuaries and post-mortem rooms. NHS Trusts should ensure that risksare reduced as far as possible – for example, by providing and maintaininga safe working environment, and ensuring staff are personally protected.Staff who work in mortuaries should be trained in the risks of their workand environment and should know how to avoid or minimise these risks.This will involve good working practice, standard operating procedures,and staff training.28

Standard operating procedures

2.37 It is the responsibility of mortuary staff to care for and keep secure thebodies of people who have died, who are brought to the mortuary forstorage and/or post-mortem examination. Procedures are needed whichwill ensure:

• all bodies, organs and other human tissues are tracked from arrivalin the mortuary to release

21Care and Respect in Death: Good Practice Guidance for NHS Mortuary Staff

26 For further information, see www.cfsms.nhs.uk.27 NHS Counter Fraud and Security Management System. A Professional Approach to Managing Security

in the NHS. 2003. Available at www.cfsms.nhs.uk.28 Health and Safety Executive. Safe Working and the Prevention of Infection in the Mortuary and Post-

mortem Room. 2003. See also A Handbook of Anatomical Pathology Technology. The Royal Institute ofPublic Health, 2004.

• bodies and any personal belongings can be located at any time

• the correct body is released to the correct recipient

• bodies are kept in the best possible condition, and protected frominterference, accidental damage or avoidable deterioration.

2.38 Standard operating procedures, and adequate facilities, are needed toachieve these objectives. Standard operating procedures should be:

• documented, signed and dated by mortuary staff and pathologistsresponsible for implementing them

• made easily accessible to staff on paper

• known to and understood by staff involved in theirimplementation, and supported by training

• reviewed and updated regularly, in line with a robust qualitymanagement system which includes a programme of scheduledaudit.

2.39 Mortuary services following good practice will have a policy in placewhich covers the procedures necessary for the identification of deceasedpeople’s bodies and their possessions. This should link to the Trust’spatient property policy.

2.40 Standard operating procedures need to be understood not only bymortuary staff but also by other staff involved in their implementation –for example, medical and nursing staff, bereavement staff, chaplains,porters, cleaners, police officers, Coroner’s officers and funeral directors.Where these or other staff, either from within or outside the Trust, areinvolved in a procedure, copies of the procedure should be made availableto them for reference – for example, on the wards, in the bereavementoffice, in the portering service office. All staff need to be regularlyupdated about mortuary procedures.

2.41 Good liaison between the mortuary and other staff and services isimportant. For example, nurses and healthcare assistants who preparedeceased people’s bodies for removal to the mortuary should be aware ofbest practice. They need information and training to enable them to carryout this task well. Staff from outside the mortuary who are involved inthis work, even if only occasionally, for example, police and newCoroner’s officers, should also be encouraged to visit the mortuary andfamiliarise themselves with the way it operates.

22Care and Respect in Death: Good Practice Guidance for NHS Mortuary Staff

Health and safety

2.42 All mortuary staff will need to be aware of current health and safetylegislation and guidance, and will receive training to enable them to worksafely.29

2.43 Staff visiting the mortuary, and visitors from outside such as healthprofessionals from the community, police officers, Coroners and Coroner’sofficers and funeral directors, must be informed of, and observe, mortuaryguidelines on health and safety, manual handling, and security.

Facilities

2.44 The standard of mortuary facilities has a direct bearing on both thesecurity and preservation of deceased people’s bodies and the health andsafety of staff, so it is essential that facilities are regularly inspected andessential maintenance work is carried out promptly. There is detailedguidance in Facilities for Mortuary and Post-Mortem Room Services.30

Mortuaries which are part of a pathology laboratory service will beinspected as part of the accreditation process (see paragraph 2.71).

Identification of the body of a person who has died

2.45 It is essential that identification of the body of a person who has died,including correlation of forms and labelling, is checked by at least twoindividuals. In Coroner’s cases, it is the responsibility of Coroner’s officersto establish identity on behalf of the Coroner by visual means or usingfingerprints, dental records or DNA (though when the person has diedin hospital, this task may be delegated to hospital staff ).

2.46 Once a person’s body is identified, it must be securely labelled, preferablywith a wrist and/or ankle band.

2.47 If there is any problem with identifying the deceased person in, forexample, a hospital setting, mortuary staff should liaise with the wardstaff who nursed the person before death and ask them to attend themortuary to identify the person positively. In the case of a ‘brought-in-dead’ body, mortuary staff must liaise with the Coroner’s officer(s) andconfirm which arrangements are in place to accomplish a positiveidentification.

23Care and Respect in Death: Good Practice Guidance for NHS Mortuary Staff

29 Health and Safety Executive. Safe Working and the Prevention of Infection in the Mortuary and Post-mortem Room. 2003.

30 NHS Estates. Facilities for Mortuary and Post-Mortem Room Services (HBN 20). 2001.

Personal possessions on or with the body of a personwho has died

2.48 Mortuary services should have a system in place to implement security ofpersonal possessions on the deceased’s body, or delivered to the mortuarywith the deceased.

2.49 Care is needed when returning personal possessions to the family. It maybe necessary to find out, as tactfully as possible, to whom the propertyshould be returned, or to check whether the person asking for theproperty is the person legally entitled to it. If there is uncertainty,enquiries should be made. There will be a recognised procedure, withappropriate liaison between mortuary staff and those outside themortuary (the bereavement team, for example). Families may also needinformation to prepare them for the condition of possessions beingreturned to them.

Release of the body of a person who has died

2.50 A member of the hospital staff, often a member of the bereavement team,will help the family if necessary to complete any documentation relatingto the person’s death. Before a deceased person’s body is released,mortuary staff should check that all necessary documentation is completeand the deceased person’s identity is confirmed, both by the mortuarystaff and by the person to whom the body is being released.

2.51 The body of a person who has died may be collected from the mortuaryby the family, but is usually released to a representative, most often afuneral director. Mortuaries should therefore ensure that they have goodlines of communication and working relationships with local funeraldirectors. An efficient system for releasing the body of the deceased alsodepends on close liaison with other staff in the hospital who are in touchwith the family – usually a member of the Trust’s bereavement team.

Good practice example: A simple precautionAPT in North Glasgow University Hospital NHS Trust: “We have a‘same name’ procedure to warn us when two of the deceased have thesame or similar names. We put a ‘same name’ label on the outside of theshroud or body bag, on any documents for the deceased, even on themortuary door. A ‘same name’ alert is put on the computer database sothat if anything is printed out for staff or funeral directors, it also carriesthe warning.”

24Care and Respect in Death: Good Practice Guidance for NHS Mortuary Staff

2.52 For information about the release of babies’ bodies direct to the family,see paragraphs 2.30 – 2.34 above.

2.53 In some cases, it will be important to inform the funeral director (or theperson to whom the deceased person’s body is being released) about thestate of the body, along with any other information that is relevant – forexample, if there has been any marked deterioration or damage. Thisshould also be documented.

2.54 If whole organs or large parts of organs have been removed duringan autopsy and it was agreed with relatives that they would be replacedin the deceased’s body, it is essential to check that this has been done.Mortuary services should have in place local protocols covering thedocumentation needed to record this (see paragraph 2.72 below).

2.55 If any organs, tissue or body parts have been removed and cannot bereturned to the deceased’s body, it is important that this is noted and thefamily is aware of it. If there has been a hospital post-mortem examinationand organs or tissue have been retained, the next of kin will already haveexpressed their wishes about what is to be done with the retained organswhen giving post-mortem consent.

2.56 Mortuary staff should make all reasonable attempts to accommodate afamily’s request for a deceased person’s body to be released quickly, andexplain the reasons for any delay. Hospitals need robust procedures inplace to ensure the bodies of people who have died are released correctly(see paragraphs 2.37 – 2.38), and common practice is to provide thehospital with a certificate of disposal (‘the green form’) before a body isreleased. However, where the death is not referred to the Coroner, anda certificate of the cause of death is available, it might be helpful toconsider what alternative documentation would be acceptable.31 Thismight be particularly appropriate when the local community includesgroups whose faith indicates vigil or early burial after death. Wherestaffing permits, arrangements for releasing a deceased person’s bodyoutside normal mortuary hours might also be considered.

2.57 In Coroners’ cases, it is important that there is an agreed protocol in placeto ensure that there is no confusion about who is responsible for thecustody and release of the bodies of the deceased.

25Care and Respect in Death: Good Practice Guidance for NHS Mortuary Staff

31 Some local authorities provide an out of hours service, including weekends, for the issue of a certificatefor disposal before the death is registered, in order to facilitate the early release of the body andsubsequent burial. While this makes early burial possible (where the death is not referred to theCoroner), the death must be registered, and specific forms obtained, before the deceased can becremated or taken out of England.

Children and babies

2.58 Mortuary services following good practice principles will considerappropriate arrangements for storage of babies who have died. They maywish to consider the following:

• documentation to make it clear that the body is a baby or child

• the bodies of babies and small children to be stored in designatedfridges

• suitable storage arrangements for the bodies and remains ofbabies born dead before 24 weeks gestation, including productsof conception, to be provided. Storage may be in the mortuary orelsewhere, depending on Trust facilities, but mortuary staff shouldbe aware that some parents of babies born dead before 24 weeks, likethe parents of stillborn babies, will wish to see, hold and spend timewith their baby, and it is important that they are enabled to do thisand receive sensitive support

• all Trusts to have in place a policy for the respectful disposal ofbabies born dead before 24 weeks gestation.32 Mortuary staff shouldbe aware of this policy and, in some Trusts, may be involved in itsimplementation.

A service that is confidential

2.59 Mortuary staff will often have access to sensitive information, both aboutpeople who have died and about bereaved families. It is essential that theymanage this information in such a way that patient confidentialitycontinues to be observed, and also that the family’s distress is minimised.In Coroner’s cases, the Coroner has a right of access to information, andhas control over what may or may not be disclosed.

2.60 Detailed and reliable documentation is essential in order to:

• check that standard operating procedures are followed

• locate, secure and track deceased bodies, organs and human tissue

26Care and Respect in Death: Good Practice Guidance for NHS Mortuary Staff

32 For further information, see Kohner N. Pregnancy Loss and the Death of a Baby. Guidelines forProfessionals. London SANDS. 1995. Department of Health advice can be found at www.dh.gov.uk,under Tissue general information.

• ensure that relevant information is recorded and accessible

• enable the collection of relevant available data for audit purposes.

2.61 Guidance on record keeping is available in Records Management: NHSCode of Practice.33

2.62 It is important that all procedures from the receipt to the release of adeceased person’s body are documented in order to:

• ensure staff can locate bodies, provide information about them, andanswer queries

• protect staff who are responsible for the safe-keeping of the bodiesand personal belongings of people who have died

• maintain complete and accurate records for audit and possiblefuture reference.

2.63 Mortuary services should have in place a policy on documentationprocedures.

A reflective service committed to improvement

2.64 It is good practice to review and audit services regularly. Changes shouldbe made where indicated, and the review process and its outcomes shouldbe recorded. Bereaved families and professional users of the service(including external users such as Coroners, local authorities who providemortuaries for the Coroner and the police who employ officers who workthere regularly, funeral directors and bereavement support organisations)should be asked to contribute to the review process, and their commentsshould be taken into account. Feedback could be sought on points suchas the following:

• is the environment safe, so staff and users feel at ease while they arethere?

• is it clean and tidy for staff and users?

• is the signage good?

27Care and Respect in Death: Good Practice Guidance for NHS Mortuary Staff

33 This is available at www.dh.gov.uk. It replaces previous guidance, including Health Service CircularHSC 1999/53 For the Record: Managing Records in NHS Trusts and Health Authorities.

• is it situated in an appropriate part of the hospital site?

• is it temporary?

• is confidential information stored securely?

2.65 The way these principles are put into practice will vary from one localityto the next and one mortuary to the next. However, mortuaries shouldnot operate in isolation from one another. It is important that informationand good practice is shared. There will be benefits in establishing andmaintaining informal networks, possibly involving others involved in careafter death – for example, those working in public mortuaries and funeraldirectors. Pathology networks can facilitate the sharing of good practice,lay involvement, training and information between mortuaries withinthe network.

A service which values good communications

2.66 Mortuary staff who have contact with families are likely to be talking tothem about sensitive, difficult issues and will be with them at a time ofgreat distress. They need good communication and interpersonal skills,and some understanding of the experience of loss. Training to developthese skills and attributes would be appropriate and very helpful.34

2.67 Families will inevitably deal with a range of hospital staff when a relativedies, and a joined-up approach is important in order to reduce the burdenon bereaved families and minimise the potential for communicationbreakdown. Mortuary staff are likely to be talking with families aboutsubjects that other professionals (clinicians, for example, or staff fromthe bereavement service) may also have talked with them about. It isimportant that everyone involved is aware of this and that the informationgiven is always consistent. For this reason, where appropriate, mortuarystaff will be involved in meetings and decision-making outside themortuary, and vice versa.

2.68 Relatives may have questions about the process which caused death, orthe circumstances around death, which mortuary staff are unable toanswer because of a lack of relevant information or training. Staff shouldhave clear routes of referral so that such technical or difficult questionscan be answered appropriately with a minimum of delay.

28Care and Respect in Death: Good Practice Guidance for NHS Mortuary Staff

34 When a Patient Dies. Advice on Developing Bereavement Services in the NHS. Department of Health,October 2005. Available at www.dh.gov.uk.

2.69 Mortuary services should have in place a policy on communicating withbereaved families. This may cover access to appropriate support if familiesneed additional services such as translation or signing.

A service that is fit for purpose

2.70 Mortuary services will have in place facilities, protocols and procedureswhich enable staff to provide the required service efficiently, effectivelyand to appropriate clinical standards.

2.71 The Department of Health has said that all NHS pathology laboratoriesshould enrol in a relevant accreditation scheme. Accreditation standardsare largely overseen by Clinical Pathology Accreditation (UK) Ltd(CPA).35 There are no accreditation standards relating specifically tomortuaries. However, accreditation standards for personnel, premises andenvironment, evaluation and quality assurance all apply. The RoyalCollege of Pathologists has also published good practice guidelines onautopsy practice.36 The Association of Anatomical PathologyTechnologists (AAPT) also provides advice on good practice;37 theHealthcare Sciences National Occupational Standards include several onAPT working practices,38 and the Royal Institute of Public Health haspublished a Handbook of Anatomical Pathology Technology.39

Good practice example: Joined-up working to provideseamless careMortuary and Bereavement Manager, Guys and St Thomas’ NHSFoundation Trust: “Trained mortuary staff (APTs) are part of thehospital’s bereavement team. This is particularly helpful if they areinvolved in the ‘consent for autopsy’ process: the APT presents a ‘face’ tothe relatives of the person who is caring for their loved one, and also hasa clear understanding of the relatives’ wishes regarding the autopsy thatcan be relayed to the pathologist at the time of the examination. A seniorAPT is identified as the lead involved with the bereavement forum, whereall care related issues are discussed, and the care of the deceased and thecare of the bereaved are brought into synch; in this way, seamless care canbe provided to the deceased and their family, carers and friends.”

29Care and Respect in Death: Good Practice Guidance for NHS Mortuary Staff

35 See www.cpa-uk.co.uk under Documents and Publications/Medical Laboratories.36 Guidelines on autopsy practice. The Royal College of Pathologists, September 2002.37 For further information, see the Association of Anatomical Pathology Technologists website at

www.aaptuk.org. 38 These are published at www.skillsforhealth.org.uk, under Completed Frameworks, Healthcare Science.39 A Handbook of Anatomical Pathology Technology. The Royal Institute of Public Health, 2004.

2.72 From 1 September 2006 all mortuaries, NHS and public authority, willrequire a licence from the regulatory body, the Human Tissue Authority(HTA), for activities including post-mortem examination and the removaland storage of human tissue. The HTA has published Codes of Practice,and will carry out inspections.40

A service which values its staff

2.73 All staff involved in delivering mortuary services should participate ineducation and training that is appropriate for their role. Trusts should,therefore, make training and learning opportunities available to mortuarystaff at all levels to enable them to develop:

• accurate, practical knowledge of hospital policy and procedures, andrelevant legislation

• an appropriate level of knowledge and understanding about death,bereavement and grief

• awareness of equality and diversity issues

• appropriate interpersonal and communication skills

• scientific and technical skills

• health and safety and infection control awareness

• quality and accountability.

2.74 This area of work can be particularly demanding, and it is importantthat staff should have access to a range of formal and informal support.Time should be allocated to ensure that staff are able to access thesupport they need.

30Care and Respect in Death: Good Practice Guidance for NHS Mortuary Staff

40 Further information, and the HTA Codes of Practice, are available on the HTA website atwww.hta.gov.uk.

2.75 As a result of the isolated location of most mortuaries and the shiftpatterns maintained by staff, a risk assessment will usually be undertakenand adherence to a Lone Worker policy encouraged among all mortuarystaff. Distressed relatives may have strong emotions which, veryoccasionally, may result in aggression directed against mortuary staff.Where risk assessments indicate a need, systems such as panic alarmsand lone worker devices should be in place and underpinned by suitableand sufficient support procedures to protect staff. Detailed guidance is setout in Not Alone: A Good Practice Guide for the Better Protection of LoneWorkers in the NHS.41

Good practice example: Looking after staffAPT at Guy’s & St Thomas’ NHS Foundation Trust: “Working in amortuary and dealing with bereaved families and individuals can beemotionally upsetting. We need to look after ourselves so that we canlook after the deceased person and the bereaved family properly. Themost senior APTs here take an active role in maintaining their ownmental well-being and that of the other APTs. We encourage staff todiscuss the day’s events as a group and talk through any feelings orthoughts they may have as a result of work. The APTs are activelyencouraged to use the Trusts’ staff counselling service.”

31Care and Respect in Death: Good Practice Guidance for NHS Mortuary Staff

41 NHS Counter Fraud and Security Management Service. Not Alone: A Good Practice Guide for the BetterProtection of Lone Workers in the NHS. March 2002. Available at www.cfsms.nhs.uk.

32Care and Respect in Death: Good Practice Guidance for NHS Mortuary Staff

Membership of the Mortuary Services sub-group ofthe National Pathology Oversight Group

Dr Ian Barnes National Clinical Lead for Pathology, Departmentof Health

Ms Mitzi Blennerhassett Member, National Pathology Oversight Group

Ms Judith Bernstein Coroners Division, Department for ConstitutionalAffairs

Mr Tony Falcon Pathology General Manager, North West LondonHospitals NHS Trust

Mr Peter Jones Bioethics Team, Department of Health

Ms Rita Joshi, succeeded byMs Lorraine Harris NHS Security Management Services

Ms Nancy Kohner Independent Consultant

Prof Sebastian Lucas Professor of Histopathology, Guys & St Thomas’NHS Foundation Trust

Mr Alan Moss, succeeded byMr James Lowell Association of Anatomical Pathology Technologists

Mr David Sowter National Association for Healthcare Security

Mr Joe Ward Manager, Greenwich Public Mortuary

Secretariat

Ms Deirdre Feehan Modernising Pathology Team, Department of Health

Mr Paul Clegg Modernising Pathology Team, Department of Health

Annex A

33Care and Respect in Death: Good Practice Guidance for NHS Mortuary Staff

Annex B

Workforce – the Anatomical Pathology TechnologyWorkforce

The current qualifications for Anatomical Pathology Technology consist of aCertificate and Diploma in Anatomical Pathology Technology awarded by theRoyal Institute of Public Health (RIPH). These are set out below.

Royal Institute of Public Health Certificate in AnatomicalPathology Technology

The course leading to this qualification, combined with on-the-job experience,prepares in-service Anatomical Pathology Technologists (APTs) and in-serviceAPT trainees to provide safe and practical assistance to the pathologist in thepost-mortem room and to maintain the mortuary in a clean and efficientmanner. It is awarded by the RIPH.

All certificate examination candidates must have:

• successfully completed a number of specified practical tasks for theCertificate, which are recorded by their supervisor in the PracticalAssessment Book, which should be submitted with each individual’sexamination entry record form. An APT will normally require upto two years training in order to complete the practical tasks

• attended an approved course of study before sitting the examination.

The assessment for the award of the Certificate is made up of three parts; apractical assessment, a written examination and an oral test, all of which testknowledge and understanding of the whole syllabus.

Royal Institute of Public Health Diploma in AnatomicalPathology Technology

The course leading to the Diploma prepares the in-service APT to providescientific and practical assistance to the pathologist in the post-mortem roomand to be proficient in all aspects of hygiene and safety. The Diploma, awardedby the RIPH, acknowledges the APT’s ability to take charge of a mortuary andto instruct assistants in safe practices. Entrants must already hold a Certificatein Anatomical Pathology Technology.

The assessment for the award of the Diploma is made up of three parts: apractical assessment, a written examination and an oral test, all of which testknowledge and understanding of the whole syllabus.

For the Future

A set of National Occupational Standards have now been approved foranatomical pathology as part of the National Occupational Standards Project inhealthcare science.42 These are currently being used as key tools in thedevelopment of competency-based career pathways for APTs.

A career framework for Healthcare Scientists in the NHS, published by theDepartment of Health in 2005, includes a recommendation to ‘ensure all eligiblestaff are on the relevant voluntary register to enable smooth transfer to a statutoryregister’. APTs can now register under a voluntary registration council43 and arelooking towards an application for statutory regulation to the Health ProfessionsCouncil (HPC).

Statutory regulation exists to ensure standards of practice by regulatedpractitioners and to protect the public as far as possible against the risk of poorpractice. It works by setting agreed standards of practice and competence, byregistering those who are competent to practise and restricting the use of specifiedtitles to those who are registered. It can also apply sanctions such as removingfrom the register any practitioner whose fitness to practise is impaired.

34Care and Respect in Death: Good Practice Guidance for NHS Mortuary Staff

42 Published at www.skillsforhealth.org.uk.43 See www.vrcouncil.org for more details.

The role of the HPC is to:

• set standards of proficiency (competence), ethics and conduct forpractitioners of a profession

• set standards of training which will produce competent, safe and effectivepractitioners in that profession

• keep a register of those who meet the standards and are fit to practice

• have a mechanism for dealing with registrants who stop meeting thestandards and need to be removed or restricted from practice, byinvestigating complaints and taking any necessary action to restrict theirpractice.

The HPC will expect any group applying to it for consideration for statutoryregulation to have in place or otherwise meet a number of criteria. Among theseis the ability to display:

• a defined body of knowledge

• evidence-based practice

• an established professional body

• a voluntary register/list of eligible practitioners

• defined entry routes

• independently assessed entry qualifications.

This means that future education and training for this group of practitioners willbe aligned to an agreed scope of practice. Discussions are under way to developthis and it is likely that education and training will be set at Foundation degreelevel, replacing both the Certificate and Diploma in one overall qualification,designed to be fit for purpose and capable of complying with the criteriaoutlined above. This will allow the profession to go forward for regulationof practice.

A voluntary register for healthcare scientists (VRCHCS) has therefore beenset up with the aim of achieving the necessary HPC criteria, and it is likely thatthe first practitioners will be able to register with the voluntary register in midto late summer 2006. The voluntary register will be open to practitioners inboth NHS and public mortuaries and will set the standards for entry to thevoluntary register. Extended roles for APTs are currently being explored withthe Royal College of Pathologists amongst others.

35Care and Respect in Death: Good Practice Guidance for NHS Mortuary Staff

36Care and Respect in Death: Good Practice Guidance for NHS Mortuary Staff

Sources of Further Information and Guidance

This document is complementary to, and intended to be read inconjunction with, other guidance; in particular:

When a Patient Dies – Advice on Developing Bereavement Services in the NHS.Department of Health, 2005. Available at www.dh.gov.uk.

Standard operating procedures.

For advice and guidance on mortuary staff working practices

A Handbook of Anatomical Pathology Technology. The Royal Institute of PublicHealth, 2004. This provides wide ranging guidance and information onmortuary work. Sections particularly relevant to this document include those ongeneral procedures and policies, and on dealing with bereaved families andvisitors in the mortuary, including arrangements for different religions, and thepossessions of the deceased.

Safe Working and the Prevention of Infection in the Mortuary and Post-mortemRoom. Health and Safety Executive, 2003.

Guidelines on Autopsy Practice. The Royal College of Pathologists, September2002.

The Healthcare Sciences National Occupational Standards (HCS NOS),published at www.skillsforhealth.org.uk. These are statements of competencedescribing good practice and are written to measure performance outcomes.Essentially they describe what needs to happen in the workplace (not whatpeople are like).

Annex C

The Human Tissue Authority (HTA) has produced Codes of Practice forConsent, Donation of organs, tissue and cells for transplantation, Post-mortemexamination, Anatomical examination and Removal, storage and disposal ofhuman organs and tissue. These codes are published on the HTA website atwww.hta.gov.uk.

Department of Health advice on disposal of babies born dead before 24 weeksgestation can be found at www.dh.gov.uk. under Tissue general information.

A Professional Approach to Managing Security in the NHS. NHS Counter Fraudand Security Management System, 2003. Available at www.cfsms.nhs.uk. Thisdocument outlines how the NHS will provide the best possible protection forits patients, staff, professionals and property.

Not Alone: A Good Practice Guide for the Better Protection of Lone Workers in theNHS. NHS Counter Fraud and Security Management Service, 2002. Availableat www.cfsms.nhs.uk.

For the Record: Managing Records in NHS Trusts and Health Authorities. This isavailable at www.dh.gov.uk. It replaces previous guidance, including HealthService Circular HSC 1999/53.

For details of the standards set by Clinical Pathology Accreditation (UK) Ltd,see www.cpa-uk.co.uk under Documents and Publications/MedicalLaboratories.

Professional guidance and support for APTs is provided by the Association ofAnatomical Pathology Technologists. See www.aaptuk.org.

For advice and guidance on supporting bereaved families

Cruse Bereavement Care has a helpline (0870 167 1677) which is linked to aBranch network. It also has a young person’s helpline (freephone – 0808 8081677) and a message board (rd4u.org.uk) providing peer support for youngpeople. Further information on a wide range of resources for families and forprofessionals can be found at the website, www.crusebereavementcare.org.uk.

Kohner N. Pregnancy Loss and the Death of a Baby. Guidelines for Professionals.London: SANDS, 1995.

The Stillbirth And Neonatal Death Society (SANDS) provides support andinformation for bereaved families, with a helpline (020 7436 5881) and adiscussion forum. Details can be found on the website at www.uk-sands.org.

37Care and Respect in Death: Good Practice Guidance for NHS Mortuary Staff

The Child Bereavement Trust has produced a wide range of resources forfamilies (bereaved children and those grieving for a child) and for professionals.Details can be found on the website at www.childbereavement.org.uk.

For advice and guidance on cultural and religious customs:

Henley A, Schott J. Culture, Religion and Patient Care in a Multi-Ethnic Society.A Handbook for Professionals. London: Age Concern, 1999.

Jogee M. Religions and Cultures – A Guide to Beliefs, Customs and Diversity forHealth and Social Care Services. 6th edition. R&C publications, Edinburgh,2004.

For advice and guidance on the built environment:

Improving the Patient Experience – A Place to Die with Dignity: Creating aSupportive Environment. NHS Estates, 2005.

Facilities for Mortuary and Post-Mortem Room Services. (NHS Estates HealthBuilding Note 20), 2001. Health Building Notes provide advice to project teamsdesigning and planning new buildings and adapting/extending existing buildings.

NHS Trusts in England and all UK government departments can downloadcore guidance (Health Building Notes etc) from the Knowledge and InformationPortal, at www.nhsestatesknowledge.dh.gov.uk, by registering for membership.All other organisations can purchase electronic copies of core guidance fromBarbour Index, 01344 884121 or IHS Technical Indexes, 01344 404429.

Other

Information on the Coroner system, and Coroner reform, can be found on thewebsite of the Department for Constitutional Affairs, at www.dca.gov.uk.

Information on the General Register Office and Registration Modernisation canbe found at www.gro.gov.uk.

38Care and Respect in Death: Good Practice Guidance for NHS Mortuary Staff

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275584/Care and Respect in Death can also be made available on request in braille, on audio cassette tape, on disk and in large print.

www.dh.gov.uk/publications